Provider Demographics
NPI:1740096049
Name:LAKESIDE MED LLC
Entity type:Organization
Organization Name:LAKESIDE MED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARMANDO
Authorized Official - Middle Name:ANTENOR
Authorized Official - Last Name:DE FERIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-392-7157
Mailing Address - Street 1:600 N HIATUS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-5207
Mailing Address - Country:US
Mailing Address - Phone:954-392-7157
Mailing Address - Fax:954-443-4941
Practice Address - Street 1:600 N HIATUS RD STE 203
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5207
Practice Address - Country:US
Practice Address - Phone:954-392-7157
Practice Address - Fax:954-443-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty